50 million missing women

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Journal of Assisted Reproduction and Genetics pp532-jarg-375546 July 31, 2002 14:46 Style file version June 3rd, 2002

Journal of Assisted Reproduction and Genetics, Vol. 19, No. 9, September 2002 ( C© 2002)

Regional–Geographic Views

The 50 Million Missing Women

Gautam N. Allahbadia1

Submitted March 14, 2002; accepted April 1, 2002

The epidemic of gender selection is ravaging countries like India & China. Approximately fiftymillion women are “missing” in the Indian population. Generally three principle causes aregiven: female infanticide, better food and health care for boys and maternal death at childbirth.Prenatal sex determination and the abortion of female fetuses threatens to skew the sex ratioto new highs. Estimates of the number of female fetuses being destroyed every year in Indiavary from two million to five million. This review from India attempts to summarize all thecurrently available methods of sex selection and also highlights the current medical practiceregards the subject in south-east Asia.

KEY WORDS: Sex selection; fetal sex determination.

Application of technology should be inconsonance with the laws of nature.

—Dr A.P.J. Abdul KalamDirector

Defence Research & DevelopmentOrganization, India

INTRODUCTION

We are not talking about long-range nuclear-tippedmissiles here, but this quote applies to the epidemicof gender selection that is ravaging countries such asIndia and China. Approximately 50 million womenare “missing” in the Indian population. Generallythree principal causes are given: female infanticide,better food and health care for boys, and mater-nal death at childbirth. The situation is similar inChina and other Asian and Middle Eastern countries.Prenatal sex determination and the abortion of fe-male fetuses threatens to skew the sex ratio to newhighs—with unknown consequences. Various meth-ods now exist for attempting to choose to have a baby

1 Rotunda – The Center For Human Reproduction, 672 KalpakGulistan, Perry Cross Road, Near Otters Club, Bandra, Mumbai400 050 India; e-mail: [email protected].

of a desired sex. In a male-oriented society such asIndia, the commonest methods employed by the vastmajority of the populace, usually after two femalechildren is ultrasound directed fetal sex determinationat 13/14 weeks gestational age and in more affluenturban areas the chorionic villus sampling techniqueat 8/9 weeks. Sex selection has become a nationalcrisis in India and China, where cheap mobile ul-trasound clinics travel the countryside testing preg-nant women. Women who discover that their fetusis female often opt for legal abortions referred toas MTPs (Medical Termination of Pregnancy). Es-timates of the number of female fetuses being de-stroyed every year in India vary from two million tofive million. This practice has reportedly skewed sexratios from the natural 106 boys to 100 girls to as highas 130 boys to 100 girls. Such results led both Chinaand India to ban ultrasound testing for the purposeof sex selection. Recognizing and seeking to controlthis perilous trend, the government of India outlawedprenatal sex determination on January 1, 1996. Thenew law makes it illegal to advertise or perform thetests (with a few exceptions) and punishes the doc-tor as well as relatives who encourage the test andthe woman herself with fines from 10 to 50 thou-sand rupees and jail terms from 3 to 5 years. But allthat this act did was to bring about an entirely new

411 1058-0468/02/0900-0411/0 C© 2002 Plenum Publishing Corporation

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underground market for sex determinations. Doctorsnow charge a premium for the services. In a bureau-cratic administrative setup, this gave corrupt govern-ment officials a lucrative business opportunity to ex-tort bribes from flourishing sex selection clinics acrossthe country.

HISTORICAL DEVELOPMENTS

Attempts to select children’s sex have a long history,from the herbal nostrums recommended by tradi-tional healers to more recent therapists’ advice aboutwhich forms of intercourse are allegedly likely to pro-duce girls or boys. The selection of gender has beena quest of couples for as far back as recorded historyallows. Early drawings from prehistoric times suggestthat sex selection efforts were being investigated byour earliest ancestors. Later history shows intense in-terest in sex selection by early Asian, Egyptian, andGreek cultures. Anaxagoras, a fifth century B.C. Greekphilosopher, believed that semen from the right tes-ticle produced sons, while semen from the left testi-cle resulted in the birth of a daughter. Believing thesame theory, men in the Balkans would squeeze theright side of their scrotums in the hope of increasingthe odds of having a son. A misconception that per-sisted till as late as the sixteenth century was that malebabies developed in the right side of the uterus. ThePerfumed Garden, written by Shaikh Nefwazi, recom-mended turning the woman on her right side after theman had ejaculated. The Charaka Samhita, a man-ual written around 800 B.C. in India, advised prospec-tive parents who expressed a preference for sons thatthey should “abstain from intercourse for a week, gaz-ing every morning and evening upon a majestic whitebull or stallion, being entertained by pleasant tales,and feeding their eyes on men and women of gentlelooks.” Mistaking vaginal secretions for semen, an-cient Greek, Hebrew, and Indian literature stated thatboth men and women produced semen. Sons wereborn when the male semen was predominant. Mas-turbation after a period of sexual abstinence usuallyresults in the ejaculation of a greater amount of se-men. Based on this observation, sexual abstinence wasrecommended for men who wanted sons. An ancientChinese birth chart predicts sex of the child based onthe age of the mother at conception and the month ofconception. This is followed by documented scientificefforts beginning in the 1600s to sway the chances ofachieving a pregnancy by a variety of methods. Re-search and work carried out in the 1980s and 1990shave finally provided methods offering the chance of

obtaining a desired pregnancy gender outcome thatranges from excellent to virtually guaranteed.

Some natural gender selection methods are basedon the observation that a conception attempt, relativeto ovulation, is more likely to result in the concep-tion of a specific sex. Attempts to time conception fora specific sex relative to ovulation have been madeby measuring hormonal levels, basal body tempera-ture, and cervical mucus observations. Other naturalmethods include radical diets, frequency and positionsof intercourse, vaginal douching, etc. These methodsare commonly used throughout the world, but the ef-fectiveness of these natural gender selection methodshave not been well documented.

MORE RECENT DEVELOPMENTS

Timing intercourse for gender selection is basedon the life and mobility of sperm; it has been sug-gested that the androsperm (Y-bearing sperm) arestronger and faster but do not survive for very long.Gynosperm, (X-bearing sperm), on the other hand,are slower but have greater staying power, conse-quently a longer life span (1). Intercourse position isalso based on the mobility of sperm, with shallow pen-etration (missionary position) favoring the concep-tion of a baby girl, with deep penetration (rear entry)favoring the conception of a baby boy (1). The WhelanMethod is in complete disagreement with the Shettlesmethod and suggests the opposite (2). Whelan saysto have intercourse 4–6 days so as to conceive aboy before your basal body temperature goes up.To conceive a girl, intercourse should occur 2–3 daysbefore ovulation.

In 1984, the World Health Organization publisheda study that failed to confirm gender predominancewhen timing conception relative to ovulation (3). Un-terburger had made observations with respect to al-kalinity and acidity and gender predetermination (4).Women recommended to use an alkaline douche (forovercoming fertility problems) conceived a higherthan usual number of boys (4).

Langendoen and Proctor first published The Pre-Conception Gender Diet in 1982, on the basis of re-sults reported by Stolkowski and Lorrain in 1980 (5).The theory is that by altering your diet to include andexclude certain foods, the conditions in the reproduc-tive tract will be directly affected, increasing the oddsof conceiving a particular sex. This theory is also con-sistent with the oriental philosophy that everythinghas a yin or yang quality and the foods supplied inthe boy diet (boys and alkaline) are all yang and the

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foods supplied in the girl diet (girls and acid) are allyin. Claims of 80% accuracy, based on one clinicaltrial of only 260 women, the results were published inthe International Journal of Gynaecology and Obstet-rics in 1980 (5). The girl diet is high in calcium but lowin salt and potassium, containing acid-forming foods.The boy diet is high in salt and potassium but low incalcium and magnesium and contains alkali-formingfoods.

The majority of the artificial sex selection meth-ods work by separating X- and Y- bearing sperm andrequire artificial insemination. The Ericsson Methodwas developed about 25 years ago and has been in clin-ical use for the last 20 years. Currently, there are over40 Sperm Centers using this procedure in the world,and over 2000 healthy babies have been born usingthe albumin treatment, the great majority of them inthe United States.

The treatment for conception of a boy involves run-ning the husband’s sperm sample through columnscontaining human serum albumin solutions of differ-ent concentrations by which Y-bearing sperm can beseparated through a filtering process (6). In January1998, Hong Kong researchers who used the Ericssonmethod (7) published a paper. They did DNA stud-ies on the supposedly X-rich and Y-rich samples pro-duced by the separation and found that each samplestill contained the original 50% ratio of X-bearing toY-bearing sperm. Many have claimed success at thistype of sperm separation, but few have been able toback up their claims with hard data.

There have been several reports in the scientific lit-erature recently which suggest that sperm subjectedto a swimup procedure and used for artificial insemi-nation can increase the chances of conceiving a maleby between 80 and 90%. In one study carried out in1993, 23 of 26 births were male claiming a successrate of about 88.5% for male sex selection (8). Tworecent studies suggest that the Percoll density gra-dient method is effective in both separating the Xand Y sperm and also skewing the birth sex ratio inhumans (9,10).

A 1996 study suggested that bottom (X) fractionsperm, derived from the eight-layer discontinuousPercoll gradient, have higher motility, progression,and hyperactivation when compared with top (Y)fraction sperm. The bottom (X) fraction sperm havegreater longevity in motility and have shorter tails,supporting earlier hypotheses of sex differences insperm parameters (9). In the Percoll procedure, thesperm sample is layered on top of a Percoll densitygradient consisting of many layers of Percoll at dif-

ferent concentrations, and the Y and X sperm are be-lieved to be partially separated at low speed inside acentrifuge by their differential sedimentation veloci-ties. The rationale to this treatment is that the X spermis believed to be bigger and heavier than the Y spermand it will sediment down the Percoll gradient quickerunder centrifugation. If sperm collected at the bottomof the Percoll gradient are used for artificial insemi-nation, the chances for conceiving a girl should begreater.

With the recent advent of Microsort (flow cytomet-ric separation of X and Y sperm) and preimplanta-tion genetic diagnosis (PGD), couples no longer havean excuse to employ abortions to select sex. The Mi-crosort method is an expensive approach to gender se-lection involving the separation of the X sperm fromthe Y sperm. This method uses a technique knownas flow cytometry where seminal fluid is filtered andthen forced through a long, thin tube under pres-sure. At the other end, the tube divides, and thereis a fluorescence-based switch, designed to direct thelarger X sperm into one direction, and the smallerY sperm into a different direction. The desired X-richor Y-rich sperm samples can then be used for artificialinsemination (11).

CULTURAL ISSUES

The problem with trying to prevent couples fromaborting female fetuses is that cultural traditions diehard, and a particularly powerful one is that boys areinfinitely more desirable than girls. The reason is sim-ple: when parents marry off a daughter, society ex-pects them to give a huge dowry to the boy’s family.This represents an enormous burden that often wipesout a family’s entire savings. Recent advertisementsin the national press and on the internet extolling the“highly effective” gender selection kit marketed by aU.S. company has created a hornet’s nest. The govern-ment is naturally perturbed about the ramificationsof such advertisements and its potential to skew thealready-tilted female–male birth ratio in the country.Recent editions of India Abroad, a weekly newspa-per for Indian expatriates in the United States andCanada, are carrying sex preselection ads by compa-nies to promote their products to one of the country’sfastest growing ethnic groups. And the target marketis immigrants from India, where sex-determinationtests were outlawed 8 years ago in a still unsuccessfuleffort to thwart the widespread practice of aborting fe-male fetuses. Such ads would be illegal in India, whichhas struggled for years to discourage women from


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exploiting medical technology to assure themselvesof giving birth to boys. Now, Indians in the UnitedStates and Canada find themselves being courted byAmerican companies that promise to help do just that.

In India and China, female infanticide is both so-cially sanctioned and undeserving of mourning. Yet,one should consider it repugnant to kill the fetus byway of abortion, especially when only done to aborta girl fetus. This would appear even more the casein our country where women deities are worshippedin various forms. In both Karnataka and Bengal thedeities of the state is a goddess.

Few of India’s states show the political will to en-force the century-old law prohibiting female infan-ticide. A ritual which originated amongst certain ofRajasthan’s tribal communities, the murder of the girlinfant, is morally cleansed by the reasoning that killingtakes place before the ritual bath, 7–10 days afterbirth, which grants an infant “human status.” This isfurther upheld by superstitions maintaining that theact enhances the chance of the next born being thepreferred son.

The killing of the infants, when born with deformi-ties of face and limbs, soon after the birth, is a frequentoccurrence in India. The culprits are the dais (tradi-tional birth attendants) and old ladies who attend tochild birth in rural communities. They, in their ownway, protect the family from the financial expensesand social stigmas associated with bringing up sucha child in a country where a lack of social educationprevents these unfortunate infants from living a fulllife and rehabilitating them. The problem has takenmonstrous proportions in just the past two decades.

Prenatal techniques for sex determination were in-troduced into India only in the early 1970s. Althoughtouted officially as an aid in reducing genetic defects,much of the Indian public has turned to these tests tofind out if “It’s a boy” or not. The effects of these de-velopments on sex ratio can be observed in every classof the society. An awareness program going right tothe grass-roots level and effective deterrent punish-ment to doctors who flout the law may be a solution.

The proliferation, and increasingly reported abuse,of prenatal testing has forced an impassioned debatethroughout India. Those fighting against the tests citestudies which suggest that a further skewing of the sexratio may only make worse the status of women, withan obvious negative impact on the whole nation. Onthe other hand, there is a great deal of public supportin India from prosex selective abortion advocates whofeel that these tools are helping families to cope withintransigent problems, especially dowry. Health clin-

ics, buoyed by record profits, are aggressively sellingtheir wares. One clever economic pitch blares fromtens of thousands of billboards through the country—Pay five hundred rupees [US$14.00] now rather thanfive lakhs [Rs 500,000 or $14,000] later. Poor families,fearing expensive dowries that can cripple a family,willingly undergo the tests. Coming on top of morethan a century of female infanticide in regions wheresons are preferred, medical technologies of amnio-centesis, ultrasound, and chorionic biopsy have com-pounded the problem of “missing females” over thepast two decades. Despite the 1994 Prenatal Diagnos-tic Techniques (Regulation and Prevention of Misuse)Act in India and China’s Human Reproductive Tech-nology Ordinance of 2000, sex determination for pur-poses of aborting female fetuses is presently a highlyprofitable medical industry. In India, the act is an “on-paper-only” law which has proven to be a toothlesstiger in the face of blatant abuse by elements of themedical fraternity. Some go so far as to suggest thatthey are helping curb the population explosion. Oth-ers defend their lucrative business, saying it offerswomen a less barbaric means than female infanticideof doing away with their daughters. Needless to say,not a single legal case has been registered in Indiaor China against those peddling their technologicalmisogyny.

Not surprisingly, proselective abortion activists feelthat selective abortion has several merits importantfor the good of the general Indian public. For exam-ple, advocates argue that selective abortion is the an-swer to population control. Perhaps they feel that ina country where families are willing to have child af-ter child until they have their desired number of sonsand daughters, sex selective abortions would allowwomen to choose the makeup of their family whilekeeping the family size small. Another argument interms of population control is that families should bebalanced; selective abortions will allow families to bal-ance their desire for a daughter with one for a son. It’sa gut-wrenching fact that in a patriarchal country likeIndia, where sons are prized and daughters devaluedin society for a variety of reasons, it is likely that cou-ples will choose to abort only females.

RECENT CHANGES

In India, requests for medically assisted sex selec-tion are very common; for example, one fertility clinicin Mumbai used to receive about 250–300 requests forY-enrichment with intrauterine inseminations each


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year till the time the Prenatal Diagnosis Act was ex-tended in 2002 to include sex selection using spermseparation techniques as well. Imprisonment for up to3 years is the deterrent used by the Union governmentagainst medical practitioners who continue to do sexdetermination tests. As I write this paper, the scenariotruly appears to change, and in 2002 the governmentseems serious and has really clamped down on clinicsoffering sex selection or sex determination. Every ul-trasound machine manufacturer has to furnish a listof the doctors to whom their units have been sold,and these doctors now have to compulsorily registerwith the government and put up boards outside theirclinics proclaiming that This clinic does not performany sex determination.

PGD FOR SEX SELECTION

There is a very affluent trader community inIndia whose religious beliefs do not allow medical ter-mination of pregnancy. It is this rich, male-orientedcommunity that has spawned a whole new breed offertility clinics attempting to offer PGD-IVF for selec-tive transfer of male embryos. Each attempt of PGD-IVF for transfer of male embryos can cost as muchas US$5000 even in a “developing” country such asIndia, where more than 50% of the populace lives be-low the poverty line. Sex selection may, therefore, be-come more acceptable to some couples, and requestsfor clinics to provide it may become more common.

IVF techniques for gender selection began witha single cell being removed from an eight-cell em-bryo under the microscope. The cell was then ana-lyzed for genetic disorders and/or gender by FISH(Fluorescence in situ hybridization). The FISH tech-nique utilizes fluorescent probes which are specifiedfor chromosomes. This technique is used for sex de-termination and for structural chromosomal abnor-malities and allows to select only the chromosoma-lly normal embryos with the desired sex for embryotransfer (8). At the 8- or 16-cell stage, embryos canbe sexed very reliably by removing one or two cellsand sexing these with FISH or PCR methods (12).Once the genders of all the embryos have been de-termined, the embryos (normally between two andfour are transferred depending on the woman’s age)of the desired sex are then replaced in the uterus. Bycombining the IVF method with sperm sorting, usingMicrosort technology, the number of male or femaleembryos could be greatly enhanced, and those em-bryos that are not replaced can be frozen and be used

in subsequent treatment cycles. This has advantages inboth reducing the cost of further treatment and min-imizing greatly the number of unwanted embryos.

Sex selection is controversial because it is the firstexample of genetic selection for a nondisease trait.Being a boy or a girl is not a disease. So should par-ents be permitted to select traits other than the sex oftheir children? Few aspects of human developmentare more significant than one’s sex; it’s a central factof one’s identity as a human being. If it is ethicallypermissible for parents to make that choice, the casefor letting them make less significant genetic choicesfor their offspring is already made. In an ethical state-ment issued last year, the American Society for Re-productive Medicine concluded that if Preconcep-tional Sex Selection is found to be safe and effective,“physicians should be free to offer pre-conceptiongender selection in clinical settings to couples whoare seeking gender variety in their offspring” (13).Some others see the use of preimplantation sex se-lection as a slippery slope to eugenics, since thesame techniques can be used to test for other genetictraits.

They might want to ponder the story of 6-year-oldMolly Nash, who suffered from the fatal genetic dis-ease, Fanconi anemia. The only cure for Molly’s dis-ease is a bone marrow transplant from a compatibledonor. Her parents used preimplantation genetic test-ing to help them bear a sibling who would be a per-fect genetic match for her. Using IVF, Molly’s parentsproduced 30 embryos that were tested for the dis-ease gene and for transplant compatibility. Only fivehad the right genetic makeup. The fourth attemptedpregnancy resulted in the birth of Adam Nash inAugust 2000. His umbilical cord blood stem cells wereused to replace Molly’s defective marrow, and nowboth children are healthy. Few people would regardwhat Molly’s parents did as immoral. After all, genetictesting in this case resulted in two valued and healthychildren.

Therefore, I strongly believe that it is sometimesethical to let parents choose their children’s sex.

REFERENCES

1. Shettles LB: Letter: Sex selection. Am J Obstet Gynecol1976;124(4):441–442

2. Daniell JF: Sex-selection procedures. J Reprod Med1983;28(4):235–237

3. World Health Organization: A prospective multi-centrestudy of the ovulation method of Natural Family Planningfor the outcome of pregnancy. Fertil Steril 1984;41:593–598


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4. Gledhill BL: Gender preselection: Historical, technical, andethical perspectives. Semin Reprod Endocrinol 1988;6(4):385–395

5. Stolkowski J, Lorrain J: Preconceptional selection of fetal sex.Int J Gynaecol Obstet 1980;18(6):440–443

6. Ericsson SA, Ericsson RJ: Sex ratio of male sex preselectedchildren born to couples with exclusively female offspring.Arch Androl 1992;28(2):121–123

7. Rose GA, Wong A: Experiences in Hong Kong with the theoryand practice of the albumin column method of sperm separa-tion for sex selection. Hum Reprod 1998;13(1):146–149

8. Check JH, Katsoff D: A prospective study to evaluate the ef-ficacy of modified swim-up preparation for male sex selection.Hum Reprod 1993;8(2):211–214

9. Watkins AM, Chan PJ, Patton WC, Jacobson JD, King A:Sperm kinetics and morphology before and after fractionation

on discontinuous Percoll gradient for sex preselection: Com-puterized analyses. Arch Androl 1996;37(1):1–5

10. Wang JX, Flaherty SP, Matthews CD: Sperm separation for sexselection. Hum Reprod 1998;13(9):2659–2661

11. Fugger EF, Black SH, Keyvanfar K, Schulman JD: Birthsof normal daughters after Microsort sperm separation andintrauterine insemination, in-vitro fertilization, or intra-cytoplasmic sperm injection. Hum Reprod 1998;13:2367–2370

12. Sills ES, Goldschlag D, Levy DP, Davis OK, Rosenwaks Z:Preimplantation genetic diagnosis: Considerations for use inelective human embryo sex selection. J Assist Reprod Genet1999;16(10):509–511

13. Ethics Committee of the American Society for Reproduc-tive Medicine. Preconception gender selection for non medicalreasons. Fertil Steril 2001;75(5):861–864


50 million missing women

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